COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facility/Site Information SAN JOAQUIN COUNTY Environmental Health Department SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 48 Hours Advance Notice Required For All Inspections Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. Job Address Phone Cross Street 01(9D -0())iik ti DOM4 S4( * Ddh.1 si-a City/Sate/Zip _514641(.4 150 &,/ / — ‘01-6 12/ APN (lo — — ()4,0 Property Owner* L,l,cir (4 t 1(5445 lqtahvirZ Phone 20404/Z1 Address 3 (AC I "C 1' A AO , city/State/Zip 5 tug kvij C/4 753C) C-57 Contractor -. ti 4) il it i A l TeS I; , License# 435 i fr5 Phone q25-3I3 -5Vr Address 9 5 -c.--, tiowe y City/State/Zip ii(oil A ki e Z-.) 0 ct (155 3 Consultant/Sub-Contractor tit 'R 'LA" I'M ( License# PG -1 Liql Phone 530-047- ;C4;.2.- City/State/Zip (4/411/40,1 Aviit) CI 5(47 CONSTRUCTION WORK TO BE PERFORMED: *Note. Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLJBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIQNS MONITORING 0 HOLLOW STEM BORING DEPTH i a I. 4... 0 BOLTED TRAFFIC BOX 0 STOVE PIPE EXTRACTION (Vapor/Water) 0 HAMMER/DRIVEN DIA. OF BOREHOLE z i I 0 MULTIPLE CASINGS 1:1 MULTI-LEVEL WELL CASING DIA SOIL VAPOR PROBE 0 MUD ROTARY CASING THICKNESS TYPE OF CASING: 0 STEEL 1:1 PVC 0 OTHER XSOIL BORING -7 5( PUSH POINT (GP/ CPT) CONDUCTOR CASING 0 Yes 0 No Boring Dia: Casing Dia: Casing Depth: INJECTION (Air Soarae 07one) 0 HAND AUGER GROUT SEAL DEPTH / TREMIE TYPE TO BE USED: 0 AUGERS HOSE EifIPE 04 o0 OTHER 0 OTHER: GROUT SEAL PUMPED? 0 Yes po (Note: Maximum Freefall Depth is 30 Ft) WELL/ SOIL BORING IDs (j91-i; GROUT SPECIFICATIONS , (Lk C‘) 1 V) Address 213X) CafftectY\ ( t4- 5501 DESTRUCTION WORK TO BE PERFORMED: # WELLS TO BE DESTROYED WELL IDs GROUT SPECIFICATIONS TREMIE TYPE TO BE USED 1:1 AUGERS 1:1 HOSE 1:1 PIPE DESTRUCTION METHOD: (CHECK ALL THAT APPLY). I1 OVER-BORE DIAMETER of inches to depth of feet PRESSURE GROUT To depth of feet below surface ['EXPLOSIVES From to feet below surface El MUSHROOM CAP El 3 feet below surface or feet below surface if >3 feet COMMENTS: I hereby certify that I am authorized to complete this application and that the work will be done in accordance with S Joaquin County Ordinance Codes and Standards, and all other ap , licable California laws., j Title/Company pmi e /lig riuyA - c 4 a-v Iv 5 E riron MilkJ/ Pv, Date Signed Print Name FA Name 4,,,-<-, L'kz"-"X (‘'"-e W2- FA Address, :>•-''--...7'.-i,...' .,4_ ,. L._ .. ;,, (1 i PR# -'--i FA PE ).,q, te•L WP Reviewed By i_ y Work Plan Date - ' -' El C-57 E(C-57 Authorization for Other to Sign Permit a(orkers Comp 0 Workers Comp Waiver 0 Encroachment Permit 12<ccess Agreement 111-tcad Agency Approval RIGIFR COMMENTS/CONDITIONS: ‘_ ,....9 %kV,. ...,-....,(1A" ei.,..,..-tm,k v•A-A-Al• WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECVD BY DATE WELL PERMIT* INVOICE# Permit 2-105 3 i js $152x _..s i LI >---,& -iii ; I L - X . 'i 7-7 1-1 0 Vit P C ) t,'," S' c: 6 i i 1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I wwvv.sicehd.com EHD 29-01 08-01-17 Site Mitigation Well Permit Application